Religious Exemption Form - Connecticut Department Of Public Health
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1
2State of Connecticut
Department of Public Health
Religious Exemption Statement
__________________________________________
(Printed full, legal name of student)
I, the undersigned, do hereby swear or affirm, as the case may be as follows:
1. I am making this Religious Exemption Statement pursuant to Conn. Gen. Stat. § 10-204a so that
the student may enroll in school for the first time or enter seventh grade at
___________________________ school.
□
□
2. I am the lawful
parent
guardian of the student.
□
□
□
student’s
parent’s
guardian’s religious
3. Immunizing said student would be contrary to
beliefs.
4. I understand that by claiming this exemption the student shall be exempt from the immunizations
required by Conn. Gen. Stat. §§ 10-204a and 19a-7f.
5. I understand that during a vaccine-preventable disease outbreak at the above-identified school, all
susceptible children, including the student will be excluded from school if a public health official
determines that the school is a significant site for disease exposure, transmission and spread into
the community. In such case, such children, including the student shall be excluded from school
until: (1) the public health official determines that the outbreak danger has ended; (2) the child
becomes ill with the disease and completely recovers from it; (3) the child is vaccinated
according to public health protocol; or (4) the child has proof of immunity to the disease.
______________________________
________________________
_______________
Name(s) of Parent(s)
Signature of Parent(s)/Guardian(s)
Date
______________________________
________________________
_______________
Name(s) of Parent(s)
Signature of Parent(s)/Guardian(s)
Date
________________________________________ __________________________________________
Address (Street & House or Apt. no.)
Telephone(s) no.
________________________________________
City, State and Zip Code
TO CLAIM A RELIGIOUS EXEMPTION, AN EXEMPTION FORM MUST BE SUBMITTED
TO THE PUBLIC OR NON-PUBLIC SCHOOL BEFORE ENROLLING IN THE SCHOOL
TH
FOR THE FIRST TIME AND BEFORE ENTERING SEVENTH (7
) GRADE.
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